Why DToCs need to be removed from the NHS lexicon

We need to stop talking about DToCs, and focus instead on how we help every patient get to the right setting of care for their needs. By Jo Andrews

In 2015, as I was moving from a career as an NHS consultant anaesthetist to join Carnall Farrar, my widowed mother had a minor fall at home and broke her ankle. She was an independent, highly articulate woman in reasonable health for her age. The break was bad, and needed surgery.

My mother was well cared for, but she waited four days for the operation and spent a week recuperating, before being discharged to a nursing home because she could not weight bear. She returned home two months after she fell, unable to climb stairs, and needing daily support. Her confidence was diminished, and she was less able to cope with even minor crises.

Finally, I understood what deconditioning was. The loss of physical capacity, confidence and independence is real, and the impact long lasting.

My mother’s case is trivial in comparison with the experiences of many older people who are admitted to hospital. The loss of physical function through loss of muscle mass, the risk of falls, pressure damage, acquired infection, and particularly for those with dementia or cognitive impairment, confusion and delirium, all have a significant impact on peoples’ ability to live independently.

Longer stay, greater impact

The longer people spend in hospital, the greater the impact. It’s bad for them, and ultimately means more people needing more care sooner than they would otherwise do. Getting people out of hospital as soon as they no longer need to be there should be a clinical, financial and humanitarian imperative.

Forty six per cent of patients audited had been medically ready to leave their current setting of care for four days or more

The headlines would have you believe that at any one time about 6,000 people are a “delayed transfer of care”. DToC was designed to create a financial incentive for local authorities to provide the services they were obliged to, by requiring them to pay a fine to the health sector when they didn’t.

It requires a detailed set of criteria to be met, and then assigns responsibility for the delay to health or social care. This is time consuming, bureaucratic, adds no value to the patient’s care, and is also damaging to partnership working, creating antagonism between health and social care with the patient in the middle.

More importantly though, it ignores a much larger group of patients who are medically fit to leave hospital, and yet remain in a hospital bed.

Over the last two years, Carnall Farrar has conducted bed audits across several sustainability and transformation partnerships, building on the excellent work undertaken by Public Health in Devon. In total, these audits cover 8 per cent of the acute bed stock, and 9 per cent of the community bed stock in England.

We have found 30 per cent of acute beds and 38 per cent of community beds are occupied by patients who are medically fit to leave. Forty six per cent of patients audited had been medically ready to leave their current setting of care for four days or more (see figure 1).

Fig 1: Time spent ”medically fit to leave”

Extrapolating this to the national bed base, we estimate 28,000 beds could be freed if patients moved to a more appropriate setting of care no more than one day after becoming medically fit.

Only one in four of the patients identified as medically fit to leave in our bed audits were classified as a DToC: we are massively underestimating the scale of the issue (see figure 2).

Fig 2: Medically fit vs DToC

Changes required

Addressing this requires changes within the hospitals themselves, at the interface with out of hospital services and in the community, where services need to support safe, prompt discharge.

Our current pattern of care keeps people in hospital beds because we haven’t prioritised the services they need to get out, and haven’t fully appreciated the harm it can do them

This cannot and must not be about providing the same care somewhere else; health and care systems have to work together to identify and put in place services at a scale that ensures they are sustainable.

Patients with increasingly complex needs require a different range of services to those currently available, and simply increasing social care capacity won’t be sufficient. But the evidence is that delaying discharge increases long term physical and psychological dependence. Our current approach to managing scarce resources is making the problem worse.

Delivering these services requires moving the resource, currently locked into providing care in hospital for patients who don’t need to be there, out of hospital. We estimate the current cost of delivering care in hospital to patients who are medically fit to be over £3bn, and the reinvestment required in new services to be £600m – £1bn.

There is scope both to move resource and address overoccupancy in hospital.

Our current pattern of care keeps people in hospital beds because we haven’t prioritised the services they need to get out, and haven’t fully appreciated the harm it can do them. The beds they are occupying are needed for other emergency and elective patients, creating a cycle of waste with clinical teams unable to deliver the care they want to, and that their patients need.

We need to stop talking about DToC, and focus instead on how we help every patient get to the right setting of care for their needs. It’s the right thing for patients, for staff and for systems.

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